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-�'--�4PPLICATION FOR WELL/PUMP PEKhI ' SAh JOAQUIN COUNTY PUBLIC HEALTH SEi DICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ' (209)468-3420 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE'SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oe In R INSTALL THE WORK DESCRIBED.TIFA 116 ICIORPLLNCE Mt If SAN JOAQVIN COUNTY DEVELOPMENT TFILE,CHAPTER II-1 1115.3 AND THE STANDARDS OF SAN JOA-IIN COUNTY PUBLIC HEALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR APNNy /��'�� „ CITY__/J�G,lL7t'�/�� (�./7Qf�PARCEL SIZEIAPNI - OWNER'S NAMES 1 i ..j.I /// f�'�7V V ADDRE68 ��[ �� c/J - PHONE I 6 r' {/C/ CONTRACTOR-- tZ�/-/ �[0 _L--� AbbRE88,,Y ._G W,47210400 ucN7-#7PHONE# 9?�.-()-:scy � -�_ t- RUB COM'RACTOR AETORE8$ UCN -�"" PRONE N�' TYPE OF VPELLJPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONHORINO WELL N ❑ OTHER f❑� INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C140190-CONNECT REPAIR ❑ VAPOR EXTRACTION-WELL a J __ I�llewAA-41lr- H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O 1T YPE OF Pt1MPl • `\Y _ � - © OUT-OF-SERVICE WFLL ❑ GEOPHYSICAL WELL N ❑ SOIL BORING B ©DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D E3 DOME STICIPMVATE ❑GRAVEL PACKIBRE TYPE OF CASINOIS1EEVPVC DIA.OF WELL CASINO Q -❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION R LD.BtRIGATIONlAG : ©OTHER GROUT SEAL INSTALLED BY GnOUT BRAND NAME F ��❑ M\MONITORING GROUT BEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:Ely. ❑No 5 APPROX.DEPTH /(�tL/ LOCKING CHESTER BOXMOVE PIPE` g PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 11-10FRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUPH COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THF BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOUCVMG:1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 114I8 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIFUNG OR SUB-CONTRACTING SIGNATURE-CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T PPL,CAN CALL 24 HOURS IN ADVANCE FOR ALL REGIIIRED INSPECTIONS AT 12MI 44W-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Rimed X Title �c ' ��•'/ PLOT PLAN R)v� to Salol Bode 'to I, I. NAM OF BTRE"S ROADS EAFtEST TO 0R BOUNDING tHE PROPERLY, s. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBEO + 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, I!1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS"THIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ......, .. ...., f... . .. - V\ r .,.:,..,..,- ..,:, ..:., .. ..... .. -- - .. .. .. ..., -- .. .. ,. O � , -c 01 AftiJrlyC1t11Nf t3tji?IY P41611C.H ALr�I5UFWI0ES >. ENVfRONNlENTAL 11ERLTH p, (� . ION r^yam DEPARTMENT VltE ONLY APPncaflon Aaaapted BY �-/� vote AfY f Orout I-p.11—BY --a.Dirta �= = �F'G11p 1niPeall 4 -- -^z-+ tea " i Vale DMt%mtl&i impeatlen B -+ '�' Data ICommdRn: i -- ACCOUNTING ONLY[ AIbN' FACN vv PE CODES FEE INFO AMOUNT REMITTED C ECK ASH RECEIVED BY DATE PFRMITISERVICE REGUEST NUMBER INVOICE 3�0 ova Pub.Hefllth Serv.-Enviro.173(1197)